6c. Fever travel/risks Flashcards

Question

invetsigation hep C

Answer 1

Hepatitis C antibody test: will be positive if the patient has ever been exposed to the hepatitis C virus, but DOESN’T mean they are actively infected HCV RNA is done in patients with a positive HCV antibody to confirm current infection, by means of a PCR.

Answer 2

1/4 self resolve, rest chronic hep C

Answer 3

cure All patients with current HCV infection (HCV RNA detected) should be offered a course of potentially curative treatment. Cure is defined as an undetectable HCV RNA in blood 12 weeks after the end of treatment (sustained virological response – “SVR12”).

Answer 4

1. NS3/4A protease inhibitors (end in –previr) e.g. grazoprevir 2. NS5A inhibitors (end in –asvir) e.g. elbasvir 3. NS5B inhibitors (end in –buvir) e.g. sofosbuvir

Answer 5

flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Answer 6

rheumatological problems: arthralgia, arthritis eye problems: Sjogren's syndrome cirrhosis (5-20% of those with chronic disease) hepatocellular cancer cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal) porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse membranoproliferative glomerulonephritis

Answer 7

Type: RNA virus Transmission: blood and bodily fluids, At risk groups include intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs). Vaccine available: no test: hep C antibody test- if positive test for RNA to confirm current infection treatment: antiviral medication for 8-12 weeks (curative in 90% of patients) grazoprevir, elbasvir, sofobuvir

Answer 8

Type: RNA virus Occurs only in people with hepatitis B infection (attaches to HBsAg) Increases complications and severity of Hep B Notifiable disease test: PCR of hep D RNA no treatment, inteferon sometimes used but poor evidence

Answer 9

Co-infection: Hepatitis B and Hepatitis D infection at the same time. Superinfection: A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection. Superinfection is associated with high risk of fulminant hepatitis, chronic hepatitis status and cirrhosis.

Answer 10

late stage HIV

Answer 11

An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until it progresses and the patient becomes immunocompromised and develops AIDS-defining illnesses and opportunistic infections potentially years later.

Answer 12

typically presents as a glandular fever type illness. Increased symptomatic severity is associated with poorer long term prognosis. It typically occurs 3-12 weeks after infection Features sore throat lymphadenopathy malaise, myalgia, arthralgia diarrhoea maculopapular rash mouth ulcers rarely meningoencephalitis

Answer 13

Unprotected anal, vaginal or oral sexual activity. Mother to child at any stage of pregnancy, birth or breastfeeding. This is referred to as vertical transmission. Mucous membrane, blood or open wound exposure to infected blood or bodily fluids such as through sharing needles, needle-stick injuries or blood splashed in an eye.

Answer 14

combined (HIV antibody and HIV p24 antigen) - if positive repeat to confirm - if negative, repeat in 3 months If exposure test: - 4 weeks after exposure and 3 months

Answer 15

500-1200 cells/mm3

Answer 16

under 200 cells/mm3

Answer 17

Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the labs recordable range (usually 50 – 100 copies/ml).

Answer 18

2 Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - eg tenofovir and emtrictiabine PLUS a third agent Often: Integrase inhibitor eg doultegrovir

Answer 19

Prophylactic co-trimoxazole (Septrin) is given to patients with CD4 < 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).

Answer 20

- viral load - CD4 count - HIV have close monitoring of cardiovascular risk factors and blood lipids and appropriate treatment (such as statins) to reduce their risk of developing cardiovascular disease. - Yearly cervical smears are required for women. HIV predisposes to developing cervical human papillomavirus (HPV) infection

Answer 21

annual influenza, pneumococcal (every 5-10 years), hepatitis A and B, tetanus, diphtheria and polio. Patients should avoid live vaccines.

Answer 22

Advise condoms for vaginal and anal sex and dams for oral sex even with when both partners are positive. If the viral load is undetectable then transmission through unprotected sex is unheard of in large studies but not impossible. Partners should have regular HIV tests. Where the affected partner has an undetectable viral load unprotected sex and pregnancy may be considered. It is also possible to conceive safely through techniques like sperm washing and IVF.

Answer 23

Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)

Answer 24

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks

Answer 25

caesarian section is recommended a zidovudine infusion should be started four hours before beginning the caesarean section

Answer 26

zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.

Answer 27

No Not recommended

Answer 28

HIV tests should be done initially but also a minimum of 3 months after exposure to confirm a negative status. Truvada (emtricitabine / tenofovir) and raltegravir for 28 days. Start within 1-2 hours - may be started up to 72 hours Individuals should abstain from unprotected activity for a minimum of 3 months until confirmed negative. see the BHIVA link for charts which outline the risk depending on the incident. Generally, low-risk incidents such as human bites don't require post-exposure prophylaxis reduces risk of transmission by 80%

Answer 29

oral thrush shingles hairy leukoplakia kaposi sarcoma

Answer 30

HHV-8 (human herpes virus 8)

Answer 31

purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract) skin lesions may later ulcerate respiratory involvement may cause massive haemoptysis and pleural effusion radiotherapy + resection

Answer 32

cryptosporidiosis cerebral toxoplasmosis Pneumocystis jirovecii pneumonia

Answer 33

commonest protozoal cause of diarrhoea in the UK. Two species, Cryptosporidium hominis and Cryptosporidium parvum account for the majority cases. Cryptosporidiosis is more common in immunocompromised patients (e.g. HIV) and young children.

Answer 34

watery diarrhoea abdominal cramps fever in immunocompromised patients, the entire gastrointestinal tract may be affected resulting in complications such as sclerosing cholangitis and pancreatitis

Answer 35

stool: modified Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the characteristic red cysts of Cryptosporidium

Answer 36

immunocompetent - supportive HIV - start antiretroviral therapy - usually resolves crypto nitazoxanide , rifaximin

Answer 37

Toxoplasma gondii is an obligate intracellular protozoan that infects the body via the gastrointestinal tract, lung or broken skin. It's oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease.

Answer 38

Most infections are asymptomatic. Symptomatic patients usually have a self-limiting infection, often having clinical features resembling infectious mononucleosis (fever, malaise, lymphadenopathy). Other less common manifestations include meningoencephalitis and myocarditis.

Answer 39

Cerebral toxoplasmosis accounts for around 50% of cerebral lesions in patients with HIV constitutional symptoms, headache, confusion, drowsiness CT: usually single or multiple ring-enhancing lesions, mass effect may be seen management: pyrimethamine plus sulphadiazine for at least 6 weeks Immunosuppressed patients may also develop a chorioretinitis secondary to toxoplasmosis.

Answer 40

Aspergillosis oesophageal candidiasis Cryptococcal meningitis (fungal) primary CNS lymphoma secondary to EBV

Answer 41

toxoplasmosis 50% primary CNS lymphoma 30%

Answer 42

toxo: Multiple lesions Ring or nodular enhancement Thallium SPECT negative lymphoma: Single lesion Solid (homogenous) enhancement Thallium SPECT positive

Answer 43

Steroids (may significantly reduce tumour size) Chemotherapy (e.g. methotrexate) + with or without whole brain irradiation. Surgical may be considered for lower grade tumours

Answer 44

cytomegalovirus retinitis

Answer 45

visual impairment e.g. 'blurred vision'. Fundoscopy shows retinal haemorrhages and necrosis, often called 'pizza' retina IV ganciclovir

Answer 46

may be due to CMV or HIV itself HSV encephalitis but is relatively rare in the context of HIV CT: oedematous brain

Answer 47

infected cells have a 'Owl's eye' appearance due to intranuclear inclusion bodies

Answer 48

usually asymptomatic can cause mononucelosis type illness

Answer 49

Gastroenteritis is a transient disorder due to enteric infection, usually caused by viruses, characterised by sudden onset of diarrhoea, with or without vomiting.

Answer 50

Dysentery is an infection of the intestines that causes diarrhoea containing blood or mucus.

Answer 51

3 or more episodes of liquid or semi-liquid stool in a 24-hour period, lasting for less than 14 days, where the stool takes the shape of the sample pot.

Answer 52

acute-onset diarrhoea that has persisted for over 14 days.

Answer 53

dehydration, electrolyte disturbance, acute kidney injury, sepsis, haemolytic uraemic syndrome, and secondary irritable syndrome or inflammatory bowel syndrome.

Answer 54

Assess for signs of dehydration, sepsis, shock (SEE DEHYDRATION AND SHOCK) 1. Arrange hospital admission if sys unwell/sepsis/severe dehydration/child with ? or confirmed STEC/?HUS 2. Arrange for stool culture and sensitivity if indicated sys unwell/dysentry/recent abx or PPI (to exclude c.diff)/diarrhoea not resolved by day 7/?food poisoning/recent travel/someone at risk of transmission/asymp been in contact with risky contacts eg confirmed STEC or giardia 3. Send additional 3 samples 2-3 days apart for ova, cysts and parasites if recent travel or symptoms >14 days 4. Hydration, ORS if at risk 5. advise abx or antimotility or antiemetics and probiotics not routinely reccomended 6. Advise measures to prevent transmission eg hygeine, 60 degrees, 48 hours symptom free before return to work 7. Notify PH fir food poisoning, HUS, infectious bloody diarrhoea, enteric fever, cholera

Answer 55

viral rotavirus in children (immunnity long lasting) norovirus in adults (immunity short lasting)

Answer 56

Sudden-onset nausea is followed by projectile vomiting and watery diarrhoea. There may be associated fever, headache, abdominal pain, and myalgia. Most people make a full recovery within 1–2 days. Symptoms begin 24–48 hours after infection and last for 12–60 hours.

Answer 57

e.coli most common campylobacter jej

Answer 58

staph aureus bacillus cereus

Answer 59

salmonella e.coli

Answer 60

shigella camylobacter

Answer 61

giardiasis amobiasis

Answer 62

e.coli 0157 shigella amobieasis

Answer 63

almost always supportive however if symptoms are severe (high fever, bloody and/or high-output diarrhoea) or the person is immunocompromised, consider early prescribing with clarithromycin 250–500 mg twice daily for 5–7 days, within 3 days of onset of illness

Answer 64

Illness is usually self-limiting and resolves within 10 days seek specialist advice for: - whether stool testing for clearance is required - monitoring for HUS

Answer 65

Short incubation period eg 6 hours, severe vomiting

Answer 66

vomiting within 6 hours, stereotypically due to rice diarrhoeal illness occurring after 6 hours

Answer 67

PC: abdo cramps, diarrhoea often with blood, vomiting, fever, flu-like prodrome Incubation 2-5 days, symptoms resolve after 3-6 days Risk factors: travel, undercooked meat (particularly poultry), unpasteurised milk, untreated water. Source often not found

Answer 68

facultative anaerobic, lactose-fermenting, Gram negative bacilli

Answer 69

PC: Watery stools with or without blood, abdominal cramps, nausea, fever. Illness is usually self-limiting and resolves within 10 days. Risk factors: travel, contact with faeces, unwashed salad, contaminated meat

Answer 70

PC: watery and sometimes bloody diarrhoea, abdominal pain, headache, nausea, vomiting, and fever. The illness usually lasts for 4–7 days, and people usually recover spontaneously. The majority of cases are sporadic, but outbreaks may occur in the general population and in institutions. Ingestion of contaminated food is the most common source, such as red and white meats, raw eggs, milk, and dairy products. Person-to-person spread and contact with infected animals can also occur.

Answer 71

Typically, 1–3 days after infection, there is diarrhoea (may have blood and mucus), fever, and abdominal cramps, with or without nausea and vomiting, headache, and malaise. Shigellosis usually resolves in 5–7 days.

Answer 72

Antibiotic treatment is not usually needed for people with mild symptoms. If symptoms are severe (high fever, bloody and/or high-output diarrhoea) or the person is immunocompromised, seek specialist advice on the need for antibiotic treatment.

Answer 73

rare infection and occurs most commonly in children. PC: watery diarrhoea (which is often bloody), fever, and abdominal pain. In older children and adults, right-sided abdominal pain and fever may occur. Symptoms typically develop 4–7 days after exposure and may last 2 days to 6 weeks. Y. enterocolitica is transmitted by direct contact with infected animals and person-to-person (faecal-oral route), and through contaminated food (especially raw pork and pork products) and water.

Answer 74

PC: profuse watery diarrhoea associated with abdominal cramps or pain, nausea, vomiting, fever, and loss of appetite. Symptoms usually last for 1–2 weeks, and recurrence of symptoms is reported in around one-third of cases. risk: recent travel, water, food

Answer 75

PC: mild diarrhoea and abdominal pain, but severe disease (amoebic dysentery) can occur, causing fever, severe abdominal pain, and blood and mucus in the faeces.

Answer 76

Drug treatment is usually recommended for all confirmed cases after specialist advice, such as metronidazole followed by the anti-protozoal drug diloxanide. (to eliminate intraluminal cysts) Seek specialist advice regarding the need for microbiological clearance to confirm treatment success, 1 week after completing treatment.

Answer 77

Amoebic liver abscess usually a single mass in the right lobe (may be multiple). The contents are often described as 'anchovy sauce' features fever right upper quadrant pain systemic symptoms e.g. malaise hepatomegaly investigations ultrasound serology is positive in > 95% management oral metronidazole a 'luminal agent' (to eliminate intraluminal cysts) is recommended usually as well e.g. diloxanide furoate

Answer 78

prolonged diarrhoea, malaise, abdominal pain, loss of appetite, flatulence, bloating, and rarely nausea. Malabsorption, weight loss, and faltering growth may occur in children

Answer 79

tinidazole 2 g as a single dose

Answer 80

haemolytic uraemic syndrome?

Answer 81

PC: brief gastroenteritis, bloody diarrhoea. 5 days after : decreased urine output, hematuria, abdo pain, lethargy, bruising, hematuria, confusion, hypertension Triad: haemolytic anaemia, acute kidney injury, thrombocytopenia

Answer 82

if has shiga toxin producing pathogen --> increases risk of HUS

Answer 83

HUS is a medical emergency and has up to 10% mortality Supportive Antihypertensives Blood transfusion Hemodialysis

Answer 84

Aspergillus = fungus Aspergillosis is an infection caused by the fungus aspergillus Aspergillioma = aspergillus growing in a cavity often created by a previous condition

Answer 85

Risk factors include: HIV Leukaemia Following broad-spectrum antibiotics

Answer 86

Usually asymptomatic but features may include cough haemoptysis (may be severe)

Answer 87

profuse 'rice water' diarrhoea, dehydration, hypoglycaemia

Answer 88

oral rehydration therapy, antibiotics: doxycycline, ciprofloxacin

Answer 89

voriconazole

Answer 90

Suspect malaria in anyone who has returned from or previously visited an area endemic for malaria, who is unwell, or has a fever or history of fever, regardless of malaria chemoprophylaxis.

Answer 91

Almost all cases of P. falciparum malaria present within 6 months of exposure and most within 2–3 months. Infection with other malaria species, such as P. ovale and P. vivax may present months or years after exposure due to reactivation of hypnozoites (a dormant liver stage). Presentation may be delayed in people who have taken chemoprophylaxis.

Answer 92

Malaria is caused by parasites from the plasmodium species. These parasites are carried by female anopheles mosquitoes and are passed onto humans when they bite. Once the parasites enter the bloodstream, they travel to the liver where they replicate within hepatocytes → these are then released into the circulation and infect red blood cells. The parasites replicate within the RBC and feed on the haemoglobin within red blood cells → ruptures RBC → infect more RBC and the cycle continues.

Answer 93

The parasites replicate within the RBC and feed on the haemoglobin within red blood cells → ruptures RBC → infect more RBC and the cycle continues The rupture of RBC leads to anaemia (haemolytic anaemia) → jaundice, splenomegaly There is also an innate immune response which leads to symptoms such as fever, chills, rigors, headache, arthralgias, myalgia Severe malaria can develop when malaria goes untreated, and is much more likely with plasmodium falciparum P.falciparum causes sequestration whereby RBC clump to endothelial cells → this can impair blood flow → ischaemic damage to organs → organ failure (which is worsened by haemolytic anaemia) anaemia + sequestration --> ischaemia + organ failure

Answer 94

think HIV seroconversion

Answer 95

? amoebic liver abscess

Answer 96

P.falciparum causes sequestration whereby RBC clump to endothelial cells → this can impair blood flow → ischaemic damage to organs → organ failure (which is worsened by haemolytic anaemia)

Answer 97

The time from infecting the RBC to bursting takes some time and when they burst there is an immune response which causes fever - this means there is a cyclical nature to the fevers eg every 24 hours/every 48 hours.

Answer 98

Impaired consciousness Extreme weakness Convulsions Acidosis (may cause hyperventilation) Hypoglycaemia Severe anaemia Renal impairment Jaundice Pulmonary oedema Significant bleeding Shock Hyperparasitaemia

Answer 99

blood film

Answer 100

thick: more sensitive thin: determine species

Answer 101

RDTs (rapid diagnostic tests) Blood film (GOLD STANDARD)

Answer 102

thrombocythaemia is characteristic normochromic normocytic anaemia normal white cell count reticulocytosis

Answer 103

refer to guidelines severe 1. artesunate uncomplicated 1. arteminisin combination therapy eg artesunate + amodiaquine (ACT)

Answer 104

5% get latent TB which becomes active a long time after infection 5% get active TB within 2 years

Answer 105

Tuberculosis usually presents with a history of chronic, gradually worsening symptoms. Most cases are of pulmonary TB (around 70%) but they often have systemic symptoms. Typical signs and symptoms of TB include: Lethargy Fever or night sweats Weight loss Cough with or without haemoptysis Lymphadenopathy Erythema nodosum Spinal pain in spinal TB (also known as Pott’s disease of the spine)

Answer 106

mantoux test - tuberculin skin prick - 5mm or more = positive Positive in previous vaccination, latent TB or actvive TB

Answer 107

Interferon-Gamma Release Assays (IGRAs) This test involves taking a sample of blood and mixing it with antigens from the TB bacteria. In a person that has had previous contact with TB the white blood cells have become sensitised to those antigens and they will release interferon-gamma as part of an immune response. If interferon-gamma is released from the white blood cells then this is considered a positive result. positive in latent TB and active TB think about pre-test probability before ordering this test

Answer 108

Sputum culture. Once cultured you can stain it (in same way as a smear) - more likely to be positive as has time to grow more sensitive than a sputum smear and nucleic acid amplification tests can assess drug sensitivities can take 1-3 weeks (if using liquid media, longer if solid media) If they are not producing sputum then hypertonic saline can be used to induce sputum that can be collected. They might require bronchoscopy with lavage to collect sputum samples. Other cultures: Mycobacterium blood cultures. These require special blood culture bottle. Lymph node aspiration or biopsy

Answer 109

It is where a sputum sample is stained wither using ziel-neelson or phenoralamine - immunofluoresence test 3 specimens are needed rapid and inexpensive test stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain) all mycobacteria will stain positive (i.e. nontuberculous mycobacteria) the sensitivity is between 50-80% this is decreased in individuals with HIV to around 20-30%

Answer 110

allows rapid diagnosis (within 24-48 hours) more sensitive than smear but less sensitive than culture It provides information about the bacteria faster than a traditional culture but is only used where having this information would affect treatment or they are at higher risk of developing complications (i.e. in HIV).

Answer 111

patchy consolidation, pleural effusions and hilar lymphadenopathy apical consolidation (top of lungs) Development of tuberculous pleural effusion may occur as a result of delayed hypersensitivity reaction to mycobacteria or mycobacterial antigens in the pleural space in sensitized individuals [10] or by rupture of a subpleural focus of pulmonary disease into the pleural space

Answer 112

upper lobe cavitation (gas filled spaces in the lungs) typically in the upper zones

Answer 113

“millet seeds” uniformly distributed throughout the lung fields

Answer 114

lungs as get plenty O2

Answer 115

cold abscess” is a firm painless abscess caused by TB, usually in the neck. They do not have the inflammation, redness and pain you would expect from an acutely infected abscess.

Answer 116

Pulmonary Extrapulmonary: lymph nodes Pleura Central nervous system Pericardium Gastrointestinal system Genitourinary system Bones and joints Cutaneous TB affecting the skin

Answer 117

the immune system is unable to control the disease this causes a disseminated, severe disease

Answer 118

intradermal injection of live attenuated (weakened) TB

Answer 119

Prior to the vaccine patients are tested with the Mantoux test and given the vaccine only if this test is negative. They are also assessed for the possibility of immunosuppression and HIV due to the risks related to a live vaccine.

Answer 120

Neonates born in areas of the UK with high rates of TB Neonates with relatives from countries with a high rate of TB Neonates with a family history of TB Unvaccinated older children and young adults (< 35) who have close contact with TB Unvaccinated children or young adults that recently arrived from a country with a high rate of TB Healthcare workers

Answer 121

Otherwise healthy patients do not necessarily need treatment for latent TB. Patients at risk of reactivation of latent TB can be treated with either: Isoniazid (with pyridoxine) and rifampicin for 3 months (good for ppl under 35 if hepatotoxcity is a concern) Isoniazid (with pyridoxine) for 6 months (for ppl where rifampicin is a concern eg HIV or post transplant)

Answer 122

combination of 4 drugs used at the same time: R – Rifampicin for 6 months I – Isoniazid for 6 months P – Pyrazinamide for 2 months E – Ethambutol for 2 months

Answer 123

pyridoxine (vitamin B6) is usually co-prescribed prophylactically to help prevent peripheral neuropathy from isoniazid

Answer 124

"red and orange pissin" hepatitis, organe secretions inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA

Answer 125

"Im-so-numb-i-said" peripheral neuropathy hepatitis, orange secretions agranulocytosis inhibits mycolic acid synthesis

Answer 126

hyperuricarmia causing gout arhtalgia, myalgia hepatitis converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I

Answer 127

“eye-thambutol” optic neuritis: check visual acuity before and during treatment dose needs adjusting in patients with renal impairment inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan

Answer 128

RIP - rifampicin - isoniazid - pyrazinamide Abdominal pain, nausea, vomiting, unexplained fatigue or jaundice - stop taking and test liver function

Answer 129

Corynebacterium diphtheriae Gram positive bacteria

Answer 130

Diphtheria toxin commonly causes a 'diphtheric membrane' on tonsils caused by necrotic mucosal cells. Systemic distribution may produce necrosis of myocardial, neural and renal tissue Possible presentations recent visitors to Eastern Europe/Russia/Asia sore throat with a 'diphtheric membrane' - grey, pseudomembrane on the posterior pharyngeal wall bulky cervical lymphadenopathy may result in a 'bull neck' appearanace neuritis e.g. cranial nerves heart block

Answer 131

Investigations culture of throat swab: uses tellurite agar or Loeffler's media Management intramuscular penicillin diphtheria antitoxin

Answer 132

VHF should be on the differential diagnosis of travellers with unexplained pyrexia returning from an affected area. It should rise very high on the list of differential diagnosis if there are features suggesting bleeding hypovolaemia increased vascular permeability organ failure. Suspected VHF is a medical and public health emergency and immediate advice should be sought from the local Communicable Disease Consultant on how to proceed[1] .

Answer 133

RNA viruses

Answer 134

1. Incubation 2-21 days 2. Viremia affecting the vascular system : flushing, conjunctival injection, petechia haemorrhage, fever, myalgia 3. Increased vascular permeability: mucous membrane haemorrhage, hypovolemia, hypotension, shock and cirucaltory collapse - Direct organ damage may be caused by the viruses themselves; multiorgan damage may also result from shock and hypovolaemia. - Different VHFs vary in their infectivity, virulence and tendency to affect specific sites such as liver, brain, kidney and lungs.

Answer 135

There may be a history of foreign travel, or of recent contact with someone who has become unwell. Remembered exposure to rodents, bats and insect bites may be significant, as may the consumption of unusual meat which might be bat or primate.

Answer 136

High temperature. Pharyngitis, conjunctival injection. Oedema, not dependent. Maculopapular, petechial or ecchymotic rash. Hypotension or shock. Haemorrhage in mucous membranes. Jaundice - sometimes seen where there is hepatic involvement. Oedema secondary to acute kidney injury In advanced disease there may be altered mental state and circulatory collapse. This may be terminal.

Answer 137

FBC shows leukopenia and thrombocytopenia, although this may not be so with Lassa fever. LFTs show elevated transaminases (in Lassa fever this predicts a high mortality). Coagulation screen: partial thromboplastin time (PTT), INR and clotting times are all prolonged. There may be evidence of DIC. D-dimer may be markedly elevated and fibrinogen levels low.

Answer 138

PCRs specific antibody tests can also be used

Answer 139

Management is supportive, focusing on blood volume management, clotting and care of major organs, including heart and lungs.

Answer 140

Dengue fever is a viral infection that can progress to viral haemorrhagic fever transmitted by the Aedes aegypti mosquito incubation period of 7 days

Answer 141

Patients with dengue fever can be classified as: - without warning signs - with warning signs - dengue haemorrhagic fever 'warning signs' include: abdominal pain hepatomegaly persistent vomiting clinical fluid accumulation (ascites, pleural effusion)

Answer 142

fever headache (often retro-orbital) myalgia, bone pain and arthralgia ('break-bone fever') pleuritic pain facial flushing (dengue) maculopapular rash haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis 'warning signs' include: abdominal pain hepatomegaly persistent vomiting clinical fluid accumulation (ascites, pleural effusion)

Answer 143

Retro-orbital headache facial flushing bone pain and arthralgia ('break-bone fever')

Answer 144

Severe dengue (dengue haemorrhagic fever) this is a form of disseminated intravascular coagulation (DIC) resulting in: thrombocytopenia spontaneous bleeding around 20-30% of these patients go on to develop dengue shock syndrome (DSS)

Answer 145

bloods- leukopenia, thrombocytopenia, raised aminotransferases diagnostic tests serology nucleic acid amplification tests for viral RNA NS1 antigen test Treatment entirely symptomatic e.g. fluid resuscitation, blood transfusion etc no antivirals are currently available

Answer 146

Type of viral haemorrhagic fever zoonotic infection: spread by Aedes mosquitos incubation period = 2 - 14 days

Answer 147

classic description involves : 1. sudden onset of high fever, rigors, nausea & vomiting. Bradycardia may develop. 2. A brief remission is followed by jaundice, haematemesis, oliguria if severe jaundice, haematemesis may occur

Answer 148

human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

Answer 149

VHF human-human transmission incubation 2-21 days

Answer 150

Ebola should be suspected in patients presenting to primary care services who have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have recently visited any of the affected areas (see maps) within the previous 21 days OR Have a fever of 37.5°C OR have a history of fever in the past 24 hours AND have cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF.

Answer 151

Typhoid and paratyphoid are caused by Salmonella typhi and Salmonella paratyphi (types A, B & C) respectively. They are often termed enteric fevers, producing systemic symptoms such as headache, fever, arthralgia. unlike other members of sanmolnella group, they more commonly cause constipation, rather than diarrhoea

Answer 152

systemic upset relative bradycardia abdominal pain distension constipation rose spots (erythematous rash on her trunk and back ) : present on the trunk in 40% of patients, and are more common in paratyphoid

Answer 153

osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens) GI bleed/perforation meningitis cholecystitis chronic carriage (1%, more likely if adult females)

Answer 154

Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The three main species of schistosome are S. mansoni, S. japonicum and S. haematobium.

Answer 155

Acute manifestations may include: - swimmers' itch - acute schistosomiasis syndrome (Katayama fever) - Chronic infections caused by Schistosoma haematobium

Answer 156

(Katayama fever) fever urticaria/angioedema arthralgia/myalgia cough diarrhoea eosinophilia

Answer 157

frequency haematuria bladder calcification (X-RAY) Investigation for asymptomatic patients serum schistosome antibodies are generally preferred for symptomatic patients the gold standard for diagnosis is urine or stool microscopy looking for eggs These worms deposit egg clusters (pseudopapillomas) in the bladder, causing inflammation. The calcification seen on x-ray is actually calcification of the egg clusters, not the bladder itself. Depending on the site of these pseudopapillomas in the bladder, they can cause an obstructive uropathy and kidney damage.

Answer 158

single oral dose of praziquantel

Answer 159

- is the pt at risk of tetanus (soil/debris/bleeding) -is the pt at increased risk of the wound being infected? eg type of wound, immunocompromised - is the pt at risk of blood borne diseases? - is the pt at risk of rabies? - is there a safe-guarding risk? DOCUMENT EVERYTHING - does the pt need abx (broken skin and drawn blood)

Answer 160

The location of the wound. Photographs or diagrams may be useful. The size, extent, and depth of the injury. The type of wound (for example laceration, puncture, abrasion, crush, haematoma, avulsion, or amputation). The degree of crush injury, devitalized tissue, nerve or tendon damage, and involvement of muscle, bones, joints, or blood vessels. Examine wounds overlying a joint through the full range of motion to detect retracted injuries and tendon rupture. Neurovascular function in the area distal to the bite — check pulses and sensation. The range and movement of any adjacent joints. Any lymphadenopathy. The presence of any foreign bodies (for example teeth) in the wound. Any signs of infection (for example redness, swelling, induration, necrotic tissue, purulent discharge, pain, localized cellulitis, lymphangitis, lymphadenopathy, or fever). Facial bites: perform an intraoral examination to exclude cheek lacerations with an intraoral communication.

Answer 161

A need for surgical intervention which is delayed for more than 6 hours. A significant amount of devitalized tissue A puncture wound (especially if in contact with soil or manure). Contamination with material likely to contain tetanus spores, such as soil or manure. A foreign body in the wound. A compound fracture. Systemic sepsis.

Answer 162

use 'green book' tetanus guidance if full childhood imms but > 10 yr ago, req tetanus booster vaccine (+ if HIGH RISK give TIG) if incomplete childhood imms - tetanus vaccine plus IM TIG TIG is tetanus immunoglobulin IM

Answer 163

If possible remove any foreign bodies (for example, teeth) from the wound. Encourage the wound to bleed (if it has just occurred), unless it is already bleeding freely. Irrigate thoroughly with warm, running water or normal saline. It is usually not possible to irrigate small puncture wounds. Consider the need for debridement (for example, if the wound is dirty or there is non-viable tissue) and refer to Accident and Emergency if this is required and the skills and resources are not available in primary care. Advise analgesia (paracetamol or ibuprofen) for pain relief, if required. Where body tissue has been torn off as a result of a bite, wrap any torn-off parts (for example, part of an ear) in clean tissue and store in a plastic bag surrounded by ice for transport to hospital. Cover the wound with an appropriate clean dressing.

Answer 164

Offer abx if a bite has broken the skin and drawn blood or if it is a deep cat bite that hasn’t drawn blood co-amoxiclav for 3 days For adults and young people aged 12 to 17 years, prescribe metronidazole plus doxycycline for 3 days. For children aged under 12 years, prescribe co-trimoxazole for 3 days.

Answer 165

UKHSA Rabies post exposure risk assessment form and calendar

Answer 166

Human bites commonly cause multimicrobial infection, including both aerobic and anaerobic bacteria. Common organisms include: Streptococci spp. Staphylococcus aureus Eikenella Fusobacterium Prevotella

Answer 167

- find out as much infor about pt and biter - any known status', vaccination history - both biter and bitten person are at risk (biter even more so) - Offer to test for Hepatitis B, Hepatitis C, and HIV - At time of incident, send 10ml clotted blood for storage - 6w later send : Hep B - HbsAg Hep C PCR HIV Ag/Ab combined test - at 3 and 6 mo send: Hep B - HbsAg Hep C Ab HIV Ag/Ab combined test

Answer 168

Gram negative rod Bartonella Henselae Cats become infected with Bartonella henselae from the bites of infected fleas or contact with infected blood

Answer 169

fever History of cat scratch Regional Lymphadenopathy Headache, malaise - one or more erythematous lesions at the site of inoculation, 3-12 days after scratch from a cat - most likely a kitten with fleas - O/e: crusted papeles or, rarely, a pustule - 1-3 weeks after primary lesion, regional lymphadenopathy appears, usually next to innoculation site - painful and may suppurate - Systemic symptoms: fever malaise, headache, anorexia

Answer 170

aseptic meningitis Encephalopathy Prolonged fever Myelitis, paraplegia, cerebral arthritis Joint pain Back pain If innoculation directly into eye —> unilateral granulomatous conjunctivitis Neuroretinitis Abdominal pain (hepatitis/splenitis)

Answer 171

supportice - antipyretics and analgesia may need fluctulant tender nodes aspirated Antibiotics are indicated in immunocompromised patients and atypical cases involving severe or systemic disease. Trimethoprim-sulfamethoxazole, ciprofloxacin or azithromycin are used first-line, with gentamicin being reserved for the severely ill patient. Patients should follow up in 2-6 months for confirmation of symptom resolution.

Answer 172

Vigilant elimination of fleas from cats.[12] Avoiding traumatic injury from cats, especially kittens. Cat-scratches and bites should be washed immediately and cats should not be allowed to lick open wounds

Answer 173

Stage 1: inoculation and localised infection PC; erythema migrans Stage 2: dissemination joints, heart, nervous system PC: flu-like illness, headache, feve, tiredness, n&v PC: facial nerve palsy, meningitis, encephalitis, peripheral mononeuritis PC: migratory joint pain PC: carditis with heartblock Stage 3: late manifestations/ dysregualted host immune response PC: chronic arthritis, encephalopathy or peripheral neuropathy, ‘post-Lyme syndrome’

Answer 174

transmitted by bite of infected Ixodes ticks The risk of transmission increases with the duration of tick attachment, with the highest risk occurring after 36-48 hours. Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi,

Answer 175

If considering testing for Lyme disease, speak to ID Erythema migrans and a history of tick bite or likely exposure Treat with oral abx for 2-3 weeks. DO NOT TEST Discuss any other cases with ID If high clinical suspicion - investigate but start treatment before results 1. ELIZA 2. Immunoblot

Answer 176

Doxycycline 100 mg bd or amoxicillin 500 mg tds. Cefuroxime 500 mg bd if both are contra-indicated and there is no history of anaphylaxis with penicillins.

Answer 177

Zoonotic disease (animal —> human) Caused by spirochaetes of the genus leptospira In humans, the infection most commonly comes from rats Disease is acquired through contact with contaminated water or soil, or through contact with urine or tissues of infected animals. Leptospires enter the bloodstream through abraded skin, mucosal membranes or conjunctiva from contaminated water or soil.

Answer 178

Infection occurs as two syndromes: anicteric (which is self-limiting, and may present as a flu-like illness) and icteric leptospirosis (a potentially severe condition also known as Weil's disease) fever Flu-like symptoms Renal failure Jaundice Subconjunctival haemorrhage Headache —> meningitis "one-week history of fever and flu-like symptoms. On examination, there is hepatomegaly, red conjunctiva and he is jaundiced. Bloods reveal an acute kidney injury and deranged liver function tests."

Answer 179

Occupational: farmers, vets, abattoir, rodent control workers, butchers, SEWAGE WORKERS, septic tank workers, rice field workers, flood relief, Recreational: open water swimming, water sports,

Answer 180

High dose benzoyl-penicillin or doxycycline Supportive care

Answer 181

Caused by the gram positive spore-forming bacterium bacillus anthracis Spores can remain dormant in soil for decades The disease occurs most often in wild and domestic animals in Asia, Africa and parts of Europe. Humans generally acquire the disease through infected animals or contaminated animal products

Answer 182

Cutaneous (from touching a dead animal or animal tanning business for example) inflamed itchy pimple —> vesicle —> ulcerates Contact with skin lesions can transmit cutaneous infection Inhalation Pulmonary anthrax: flu-like, nausea, vomiting, sore throat, cough, sweats,fever, confusion, headache and myalgia. Patients also develop pallor or cyanosis, dyspnoea, tachycardia, abdominal pain and pleuritic chest pain

Answer 183

call ID and infection control TREAT IF CLINICAL SUSPICION. HIGH MORTALITY IF DELAYED 60 days of 3 abx continually review resp support need - can deteriorate v quickly

Answer 184

Botulism is caused by botulinum toxin which is a poison produced by the obligate anaerobic bacteria Clostridium botulinum, Clostridium baratii and Clostridium butyricum. The organism is common in the soil and can survive in this environment in the form of a resistant spore.

Answer 185

food botulism - airtight container, uncooked food wound botulism - IVDU

Answer 186

Acute symmetrical, descending, flaccid paralysis blurred vision. difficulty in swallowing and speaking. diarrhoea and vomiting. descending weakness or paralysis, that may extend to complete flaccid paralysis. The patient remains alert.

Answer 187

Acute onset of bilateral cranial nerve involvement. Failure of accommodation. Pupils fixed in mid position or dilated. Fever is unusual, as is loss of sensation

Answer 188

resp support anti-toxin